Hepatogenous Diabetes as Compared to Type-2 Diabetes Mellitus and Non-diabetes in Patients With Liver Cirrhosis: Magnitude, Characteristics, and Implications.

Aim: Hepatogenous diabetes (HD) is frequently underestimated among cirrhosis patients. The current study assessed the magnitude, clinical characteristics, and implications of HD in cirrhosis patients as compared to the patients with type-2 diabetes mellitus (T2DM) and non-diabetes (ND) cirrhosis. Methods: In a prospective observational study, 338 consecutive eligible cirrhosis patients were screened for diabetes mellitus. A 2-hour oral glucose tolerance test (OGTT) was used to detect HD. The clinical characteristics, complications, and outcomes were ascertained and compared amongst HD, T2DM, and ND patients. Results: In the final study cohort of 316 patients, the proportion of HD, T2DM, and ND was 22.5% (n = 71), 26.3% (n = 83), and 51.3% (n = 162), respectively. HD was the predominant form of diabetes (68.9%) in Child-Pugh class-C cirrhosis. The majority (73%) of HD patients had abnormal OGTT without fasting hyperglycaemia. A lower cut-off of 98.5 mg/dl for fasting blood glucose had a modest sensitivity (72%) and specificity (75%) for predicting HD. In comparison to T2DM patients, HD patients were younger, leaner, and had more advanced cirrhosis. In comparison to ND patients, HD patients were leaner but had higher glycemic indices, serum cholesterol, and arterial ammonia levels. During a median follow-up period of 12 (03-21) months, the frequency of hepatic encephalopathy and variceal haemorrhage were higher in HD and T2DM patients compared to that in the ND group. Conclusions: HD is prevalent in about one fifth of cirrhosis patients. It differs from T2DM and ND in a number of ways, and has association with complications of cirrhosis.

Amebic liver abscess: An update.

Amebic liver abscess (ALA) is still a common problem in the tropical world, where it affects over three-quarters of patients with liver abscess. It is caused by an anaerobic protozoan Entamoeba hystolytica, which primarily colonises the cecum. It is a non-suppurative infection of the liver consisting primarily of dead hepatocytes and cellular debris. People of the male gender, during their reproductive years, are most prone to ALA, and this appears to be due to a poorly mounted immune response linked to serum testosterone levels. ALA is more common in the right lobe of the liver, is strongly associated with alcohol consumption, and can heal without the need for drainage. While majority of ALA patients have an uncomplicated course, a number of complications have been described, including rupture into abdomino-thoracic structures, biliary fistula, vascular thrombosis, bilio-vascular compression, and secondary bacterial infection. Based on clinico-radiological findings, a classification system for ALA has emerged recently, which can assist clinicians in making treatment decisions. Recent research has revealed the role of venous thrombosis-related ischemia in the severity of ALA. Recent years have seen the development and refinement of newer molecular diagnostic techniques that can greatly aid in overcoming the diagnostic challenge in endemic area where serology-based tests have limited accuracy. Metronidazole has been the drug of choice for ALA patients for many years. However, concerns over the resistance and adverse effects necessitate the creation of new, safe, and potent antiamebic medications. Although the indication of the drainage of uncomplicated ALA has become more clear, high-quality randomised trials are still necessary for robust conclusions. Percutaneous drainage appears to be a viable option for patients with ruptured ALA and diffuse peritonitis, for whom surgery represents a significant risk of mortality. With regard to all of the aforementioned issues, this article intends to present an updated review of ALA.

Comparison of short-term outcomes of open and laparoscopic assisted pancreaticoduodenectomy for periampullary carcinoma: A propensity score-matched analysis.

Backgrounds/Aims: Postoperative pancreatic fistula is the key worry in the ongoing debate about the safety and effectiveness of total laparoscopic pancreaticoduodenectomy (TLPD). Laparoscopic-assisted pancreaticoduodenectomy (LAPD), a hybrid approach combining laparoscopic resection and anastomosis with a small incision, is an alternative to TLPD. This study compares the short-term outcomes and oncological efficacy of LAPD vs. open pancreaticoduodenectomy (OPD). Methods: A retrospective analysis of data of all patients who underwent LAPD or OPD for periampullary carcinoma at a tertiary care center in Northeast India from July 2019 to August 2023 was done. A total of 30 LAPDs and 30 OPDs were compared after 1:1 propensity score matching. Demographic data, intraoperative and postoperative data (30 days), and pathological data were compared. Results: The study included a total of 93 patients, 30 underwent LAPD and 62 underwent OPD. After propensity score matching, the matched cohort included 30 patients in both groups. The LAPD presented several advantages over the OPD group, including a shorter incision length, reduced postoperative pain, earlier initiation of oral feeding, and shorter hospital stays. LAPD was not found to be inferior to OPD in terms of pancreatic fistula incidence (Grade B, 30.0% vs. 33.3%), achieving R0 resection (100% vs. 93.3%), and the number of lymph nodes harvested (12 vs. 14, p = 0.620). No significant differences in blood loss, short-term complications, pathological outcomes, readmissions, and early (30-day) mortality were observed between the two groups. Conclusions: LAPD has comparable safety, technical feasibility, and short-term oncological efficacy.

Self-Defensive Antimicrobial Shape Memory Polyurethanes with Honey-Based Compounds.

Infection treatment plays a crucial role in aiding the body in wound healing. To that end, we developed a library of antimicrobial polymers based on segmented shape memory polyurethanes with nondrug-based antimicrobials (i.e., honey-based phenolic acids (PAs)) using both chemical and physical incorporation approaches. The antimicrobial shape memory polymers (SMPs) have high transition temperatures (>55 °C) to enable maintenance of temporary, programmed shapes in physiological conditions unless a specific external stimulus is present. Polymers showed tunable mechanical and shape memory properties by changing the ratio, chemistry, and incorporation method of PAs. Cytocompatible (∼100% cell viability) synthesized polymers inhibited growth rates of Staphylococcus aureus (∼100% with physically incorporated PAs and >80% with chemically incorporated PAs) and Escherichia coli (∼100% for samples with cinnamic acid (physical and chemical)). Crystal violet assays showed that all formulations inhibit biofilm formation in surrounding solutions, and chemically incorporated samples showed surface antibiofilm properties with S. aureus. Molecular dynamics simulations confirm that PAs have higher levels of interactions with S. aureus cell membranes than E. coli. Long-term antimicrobial properties were measured after storage of the sample in aqueous conditions; the polymers retained their antimicrobial properties against E. coli after up to 20 days. As a proof of concept, magnetic particles were incorporated into the polymer to trigger user-defined shape recovery by applying an external magnetic field. Shape recovery disrupted preformed S. aureus biofilms on polymer surfaces. This antimicrobial biomaterial platform could enable user- or environmentally controlled shape change and/or antimicrobial release to enhance infection treatment efforts.

Prevalence and risk factors of lymphatic dysfunction in cirrhosis patients with refractory ascites: An often unconsidered mechanism.

BACKGROUND: The lymphatic system is crucial in maintaining the body fluid homeostasis. A dysfunctional lymphatic system may contribute to the refractoriness of ascites and edema in cirrhosis patients. Therefore, assessment of lymphatic dysfunction in cirrhosis patients with refractory ascites (RA) can be crucial as it would call for using different strategies for fluid mobilization. AIM: To assessing the magnitude, spectrum, and clinical associations of lymphatic dysfunction in liver cirrhosis patients with RA. METHODS: This observational study included 155 consecutive cirrhosis patients with RA. The presence of clinical signs of lymphedema, such as peau d'orange appearance and positive Stemmer sign, intestinal lymphangiectasia (IL) on duodenal biopsy seen as dilated vessels in the lamina propria with strong D2-40 immunohistochemistry, and chylous ascites were used to diagnose the overt lymphatic dysfunctions. RESULTS: A total of 69 (44.5%) patients out of 155 had evidence of lymphatic dysfunction. Peripheral lymphedema, found in 52 (33.5%) patients, was the most common manifestation, followed by IL in 42 (27.0%) patients, and chylous ascites in 2 (1.9%) patients. Compared to patients without lymphedema, those with lymphedema had higher mean age, median model for end-stage liver disease scores, mean body mass index, mean ascitic fluid triglyceride levels, and proportion of patients with hypoproteinemia (serum total protein < 5 g/dL) and lymphocytopenia (< 15% of total leukocyte count). Patients with IL also had a higher prevalence of lymphocytopenia and hypoproteinemia (28.6% vs. 9.1%, P = 0.004). Seven (13%) patients with lymphedema had lower limb cellulitis compared to none in those without it. On multivariate regression analysis, factors independently associated with lymphatic dysfunction included obesity [odds ratio (OR): 4.2, 95% confidence intervals (95%CI): 1.1-15.2, P = 0.027], lymphocytopenia [OR: 6.2, 95%CI: 2.9-13.2, P < 0.001], and hypoproteinemia [OR: 3.7, 95%CI: 1.5-8.82, P = 0.003]. CONCLUSION: Lymphatic dysfunction is common in cirrhosis patients with RA. Significant indicators of its presence include hypoproteinemia and lymphocytopenia, which are likely due to the loss of lymphatic fluid from the circulation. Future efforts to mobilize fluid in these patients should focus on methods to improve lymphatic drainage.

Long-term complications after extrahepatic cyst excision for type IV-A choledochal cysts.

Forty-five adults with type IV-A choledochal cysts (CDC) who underwent extrahepatic cyst excision from January 2013 to December 2021 were followed up for a median interval of 25 months (range, 2 to 10 years) to observe the long-term complications in the remaining intrahepatic cyst. Late complications in varying combinations were seen in 10 patients, which included cholangitis and/or intrahepatic stones in 9 patients, intrahepatic bile duct stenosis with stones in 2 patients, anastomotic stricture in 6 patients, and left lobar atrophy with intrahepatic stones in 3 patients. Out of 6 patients who required re-do hepaticojejunostomy (HJ), three patients had left lobe atrophy with patent HJ anastomosis and a recurrent attack of cholangitis on follow-up at 3, 8, and 10 years. Complications occur frequently after extrahepatic cyst excision for type IV-A CDC and require a long-term follow-up.

In vitro and in vivo degradation correlations for polyurethane foams with tunable degradation rates.

Polyurethane foams present a tunable biomaterial platform with potential for use in a range of regenerative medicine applications. Achieving a balance between scaffold degradation rates and tissue ingrowth is vital for successful wound healing, and significant in vivo testing is required to understand these processes. Vigorous in vitro testing can minimize the number of animals that are required to gather reliable data; however, it is difficult to accurately select in vitro degradation conditions that can effectively mimic in vivo results. To that end, we performed a comprehensive in vitro assessment of the degradation of porous shape memory polyurethane foams with tunable degradation rates using varying concentrations of hydrogen peroxide to identify the medium that closely mimics measured in vivo degradation rates. Material degradation was studied over 12 weeks in vitro in 1%, 2%, or 3% hydrogen peroxide and in vivo in subcutaneous pockets in Sprague Dawley rats. We found that the in vitro degradation conditions that best predicted in vivo degradation rates varied based on the number of mechanisms by which the polymer degraded and the polymer hydrophilicity. Namely, more hydrophilic materials that degrade by both hydrolysis and oxidation require lower concentrations of hydrogen peroxide (1%) to mimic in vivo rates, while more hydrophobic scaffolds that degrade by oxidation alone require higher concentrations of hydrogen peroxide (3%) to model in vivo degradation. This information can be used to rationally select in vitro degradation conditions that accurately identify in vivo degradation rates prior to characterization in an animal model.

Sarcopenia in Chronic Liver Disease: A Metabolic Perspective.

Sarcopenia, a condition of low muscle mass, quality, and strength, is commonly found in patients with chronic liver disease (CLD) and is associated with adverse clinical outcomes including reduction in quality of life, increased mortality, and complications. A major contributor to sarcopenia in CLD is the imbalance in muscle protein turnover wherein changes in various metabolic factors such as hyperammonemia, amino acid deprivation, hormonal imbalance, gut dysbiosis, insulin resistance, chronic inflammation, etc. have important roles. In particular, hyperammonemia is a key mediator of the liver-gut axis and is known to contribute to sarcopenia by various mechanisms including increased expression of myostatin, increased phosphorylation of eukaryotic initiation factor 2a, cataplerosis of α-ketoglutarate, mitochondrial dysfunction, increased reactive oxygen species that decrease protein synthesis and increased autophagy-mediated proteolysis. Skeletal muscle is a major organ of insulin-induced glucose metabolism, and sarcopenia is closely linked to insulin resistance and metabolic syndrome. Patients with liver cirrhosis are in a hypermetabolic state that is associated with catabolism and depletion of amino acids, particularly branched-chain amino acids. Sarcopenia can have significant implications for nonalcoholic fatty liver disease, the most common form of CLD worldwide, because of the close link between metabolic syndrome and sarcopenia. This review discusses the potential metabolic derangement as a cause or effect of sarcopenia in CLD, as well as interorgan crosstalk, which that might help identifying a novel therapeutic strategies.

Efficacy of intravenous vitamin C in management of moderate and severe COVID-19: A double blind randomized placebo controlled trial.

Aim: To study the efficacy of intravenous vitamin C in management of moderate and severe COVID-19. Objective: To determine the efficacy of intravenous vitamin C in reducing in-hospital mortality in moderate and severe cases of COVID-19. Design: Parallel, double-blinded randomized controlled trial with placebo. Ethical clearance was obtained from the institutional ethics committee, AIIMS Patna. The trial was registered with the Clinical Trials Registry - India (registration number- CTRI/2020/11/029230.). Setting: A tertiary care centre in Bihar, India. Participants: All patients above the age of 18 years both males and females, admitted in ICU with a diagnosis of moderate and severe COVID-19 (on the basis of a positive reverse transcriptase polymerase chain reaction (RT-PCR) report) at our facility during the study period (01/10/2020-31/12/2020) not having any of the exclusion criteria. Intervention: The patients in the intervention arm were given 1 gram (2 ampoules of 2 ml each containing 500 mg of vitamin C mixed in 100 ml normal saline) intravenous vitamin C 8 hourly for four days. The patients in the placebo arm received similar looking ampoules (2 ampoules of 2 ml sterile water for injection mixed in 100 ml normal saline) intravenously 8 hourly for four days. The rest of the treatment was given as per the standard operating procedure (SOP) of the institute with adjustments as per treating team's judgement. Outcome Measures: Primary outcome was reduction in in-hospital mortality. Secondary outcomes were improvement in qSOFA score, pO2/fiO2 ratio, fall in inflammatory markers, need for mechanical ventilation and vasopressors. Results: Regarding primary outcome, 10 (33.3%) patients died in intervention group compared to 13 (43.3%) in placebo. Worth noting from baseline characteristics is that 86.7% in intervention arm were of severe category compared to 66.7% severe category patients in placebo group. Though number of severe cases were more in intervention arm there has been comparatively less mortality in this group. Regarding secondary outcomes, amongst 30 patients in vitamin C group, 11 (36.7%) required invasive mechanical ventilation compared to 14 (46.7%) out of 30 in placebo group but the difference was not statistically significant. Although there were a greater number of moderate cases in placebo group, invasive ventilation requirement (and NIV requirement) was more in this group, thus it could be considered that vitamin C might have a role in reducing the severity of disease. The need for vasopressor therapy was higher in intervention arm 33.3% compared to 26.7% in placebo but not significant statistically. The secondary outcomes of the study such as improvement in organ failure score (qSOFA Score), fall in level of inflammatory markers, improvement in respiratory index (pO2/fiO2 ratio), need for mechanical ventilation and need for vasopressors also shown encouraging results but not up to the statistically significant level due to moderate dosage of the drug and small sample size. Conclusion: In the current study, by the observations and results of the double-blind placebo controlled randomised trial, we concluded that as the primary outcome of the study, there was reduction in In-hospital mortality and need for mechanical ventilation in the vitamin C intervention group compared to placebo, although these results did not reach statistical significance due to small sample size and use of moderate dose of IV vitamin C. The secondary outcomes of the study such as improvement in organ failure score (qSOFA Score), fall in level of inflammatory markers, improvement in respiratory index (pO2/fiO2 ratio), need for mechanical ventilation and need for vasopressors also shown encouraging results but not up to the statistically significant level due to moderate dosage of the drug and small sample size. In summary, high dose of intravenous vitamin C may reduce inflammatory reaction, improve oxygen support status, and reduce mortality in COVID-19 patients, without adverse events. High dose intravenous vitamin C may be a promising therapy for patients of moderate to severe COVID-19.

Association of COVID-19 with hepatic metabolic dysfunction.

The coronavirus disease 2019 (COVID-19) pandemic continues to be a global problem with over 438 million cases reported so far. Although it mostly affects the respiratory system, the involvement of extrapulmonary organs, including the liver, is not uncommon. Since the beginning of the pandemic, metabolic com-orbidities, such as obesity, diabetes, hypertension, and dyslipidemia, have been identified as poor prognostic indicators. Subsequent metabolic and lipidomic studies have identified several metabolic dysfunctions in patients with COVID-19. The metabolic alterations appear to be linked to the course of the disease and inflammatory reaction in the body. The liver is an important organ with high metabolic activity, and a significant proportion of COVID-19 patients have metabolic comorbidities; thus, this factor could play a key role in orchestrating systemic metabolic changes during infection. Evidence suggests that metabolic dysregulation in COVID-19 has both short- and long-term metabolic implications. Furthermore, COVID-19 has adverse associations with metabolic-associated fatty liver disease. Due to the ensuing effects on the renin-angiotensin-aldosterone system and ammonia metabolism, COVID-19 can have significant implications in patients with advanced chronic liver disease. A thorough understanding of COVID-19-associated metabolic dysfunction could lead to the identification of important plasma biomarkers and novel treatment targets. In this review, we discuss the current understanding of metabolic dysfunction in COVID-19, focusing on the liver and exploring the underlying mechanistic pathogenesis and clinical implications.

Antimicrobial Shape Memory Polymer Hydrogels for Chronic Wound Dressings.

Chronic wounds can remain open for several months and have high risks of amputation due to infection. Dressing materials to treat chronic wounds should be conformable for irregular wound geometries, maintain a moist wound bed, and reduce infection risks. To that end, we developed cytocompatible shape memory polyurethane-based poly(ethylene glycol) (PEG) hydrogels that allow facile delivery to the wound site. Plant-based phenolic acids were physically incorporated onto the hydrogel scaffolds to provide antimicrobial properties. These materials were tested to confirm their shape memory properties, cytocompatibility, and antibacterial properties. The incorporation of phenolic acids provides a new mechanism for tuning intermolecular bonding in the hydrogels and corollary mechanical and shape memory properties. Phenolic acid-containing hydrogels demonstrated an increased shape recovery ratio (1.35× higher than the control formulation), and materials with cytocompatibility >90% were identified. Antimicrobial properties were retained over 20 days in hydrogels with higher phenolic acid content. Phenolic acid retention and antimicrobial efficacy were dependent upon phenolic acid structures and interactions with the polymer backbone. This novel hydrogel system provides a platform for future development as a chronic wound dressing material that is easy to implant and reduces infection risks.

Magnetically Actuated Shape Memory Polymers for On-Demand Drug Delivery.

Repeated use of intravenous infusions to deliver drugs can cause nerve damage, pain, and infection. There is an unmet need for a drug delivery method that administers drugs on demand for prolonged use. Here, we developed magnetically responsive shape memory polymers (SMPs) to enhance control over drug release. Iron oxide magnetic nanoparticles (mnps) were synthesized and incorporated into previously developed SMPs to enable magnetically induced shape memory effects that can be activated remotely via the application of an alternating magnetic field. These materials were tested for their shape memory properties (dynamic mechanical analysis), cytocompatibility (3T3 fibroblast viability), and tunable drug delivery rates (UV−VIS to evaluate the release of incorporated doxorubicin, 6-mercaptopurine, and/or rhodamine). All polymer composites had >75% cytocompatibility over 72 h. Altering the polymer chemistry and mnp content provided methods to tune drug release. Namely, linear polymers with higher mnp content had faster drug release. Highly cross-linked polymer networks with lower mnp content slowed drug release. Shape memory properties and polymer/drug interactions provided additional variables to tune drug delivery rates. Polymers that were fixed in a strained secondary shape had a slower release rate compared with unstrained polymers, and hydrophobic drugs were released more slowly than hydrophilic drugs. Using these design principles, a single material with gradient chemistry and dual drug loading was synthesized, which provided a unique mechanism to deliver two drugs from a single scaffold with distinct delivery profiles. This system could be employed in future work to provide controlled release of selected drug combinations with enhanced control over release as compared with previous approaches.

Amebic liver abscess: Clinico-radiological findings and interventional management.

In its classic form, amebic liver abscess (ALA) is a mild disease, which responds dramatically to antibiotics and rarely requires drainage. However, the two other forms of the disease, i.e., acute aggressive and chronic indolent usually require drainage. These forms of ALA are frequently reported in endemic areas. The acute aggressive disease is particularly associated with serious complications, such as ruptures, secondary infections, and biliary communications. Laboratory parameters are deranged, with signs of organ failure often present. This form of disease is also associated with a high mortality rate, and early drainage is often required to control the disease severity. In the chronic form, the disease is characterized by low-grade symptoms, mainly pain in the right upper quadrant. Ultrasound and computed tomography (CT) play an important role not only in the diagnosis but also in the assessment of disease severity and identification of the associated complications. Recently, it has been shown that CT imaging morphology can be classified into three patterns, which seem to correlate with the clinical subtypes. Each pattern depicts its own set of distinctive imaging features. In this review, we briefly outline the clinical and imaging features of the three distinct forms of ALA, and discuss the role of percutaneous drainage in the management of ALA.

Occupational Hazards of Surgical Smoke and Achieving a Smoke Free Operating Room Environment: Asia-Pacific Consensus Statement on Practice Recommendations.

Background: Surgical smoke generated through energy devices may present detrimental effects on individuals present in the operating room (OR). Despite the concerns possibly associated with surgical smoke, there may be no mandatory policies that suggest protective measures and limited firm standards are committed yet to address the same. Aim: The aim of this paper is to present recommendations for surgeons and OR personnel by taking a consensus approach based on available literature and its interpretation by a multi-national panel of experts. Methods: The Asia-Pacific (APAC) group was established with the aims of reviewing literature evidence, discussing key issues regarding surgical smoke and its hazards, and offering a summary of statements in achieving a smoke-free OR environment. Eleven expert surgeons from the international APAC region were gathered with the purpose of coming to a consensus on engineering, best work-practices, and administrative controls in minimizing surgical smoke exposure. A two-phase consensus method was used to obtain opinions from the expert panel of specialists. Statements with an agreement of more than 80% were accepted. Findings: For twenty-one statements, the panel achieved consensus on 17 statements; another 5 were dropped due to lack of consensus. The consensus was obtained on statements that address the need for the implementation of administrative policies, training and awareness, standard procedure for the continued use of engineering controls, stringent work practice controls and preventive controls. Conclusion: The statements presented may guide surgeons and OR personnel in the practical management of surgical smoke safety, mitigating the risks associated with it. The consensus statement also provides a series of recommendations that can be used with other stakeholders, such as policymakers, hospital administrators and professional societies, to highlight and motivate the implementation of meaningful policies.

Shape memory polymer foams with tunable interconnectivity using off-the-shelf foaming components.

The ability to easily and safety tune pore structures of gas-blown polyurethane shape memory polymer (SMP) foams could improve their outcomes as hemostatic dressings or tissue engineering scaffolds and enable overall commercialization efforts. Incorporating physical blowing agents into the polymer mix can be used to tune pore size and interconnectivity without altering foam chemistry. Enovate (HFC-254fa) is a commonly used physical blowing agent in gas-blown foams, but the Environmental Protection Agency (EPA) considers its use unacceptable because it is a hydrofluorocarbon that contributes to global warming. Here, off-the-shelf solvents accepted for use by the EPA, acetone, dimethyoxymethane (methylal), and methyl formate, were used as physical blowing agents by adding small volumes during foam fabrication. Increasing the physical blowing agent volume resulted in greater pore interconnectivity while maintaining SMP foam chemical and thermal properties. Pore size and interconnectivity also impacted cell and blood interactions with the foams. This work provides a safe and easy method for tuning SMP foam interconnectivity to aid in future commercialization efforts in a range of potential biomedical applications.

Giant Adrenal Pseudocysts: An Enigma for Surgeons.

Adrenal pseudocysts are cystic lesions arising within the adrenal gland enclosed by a fibrous connective tissue wall that lacks lining cells. They can attain a huge size and pose a diagnostic challenge with a broad range of differentials including benign and malignant neoplasms. There are only a few small case series and case reports describing these lesions. We report a series of five patients who presented with "indeterminate" abdominal cystic lesions and were later on found to have adrenal pseudocyst. Four out of five patients presented with non-specific abdominal symptoms, and one patient presented with symptoms suggestive of a functional adrenal tumor. The size of these tumors ranged from 6 to 30 cm. They had variable radiological features and in two cases even a percutaneous biopsy could not establish the diagnosis. In four of these "indeterminate" abdominal masses, an adrenal origin was not suspected preoperatively. Surgical excision provided a resolution of symptoms, ruled out malignancy, and clinched the diagnosis.

Large Hepatic Subcapsular Hematoma Following Endoscopic Retrograde Cholangiopancreatography: A Case Report.

For decades, endoscopic retrograde cholangiopancreatography (ERCP) has been the cornerstone in the treatment of several biliopancreatic diseases. Although it is a relatively safe procedure, there are certain hazards involved. Hepatic subcapsular hematoma (HSH) is an uncommon complication of ERCP, with only a few cases reported in the literature to date. We present here a case of large HSH that developed 48 hours after an otherwise uneventful ERCP for choledocholithiasis. After being apparently well for the first two days post-ERCP, the patient began to develop abdominal pain and restlessness associated with hemodynamic instability and a decline in hemoglobin levels. Computed tomography (CT) confirmed the presence of a large HSH. The patient was managed nonsurgically with vascular angioembolization followed by ultrasound-guided percutaneous catheter drainage of hematoma. This case highlights the necessity of increasing awareness about this complication in order to aid in early diagnosis and management.

Invasive investigation in cases of visceral AVM may be fatal: A rare case report.

INTRODUCTION AND IMPORTANCE: Visceral arteriovenous malformations (AVMs) are extremely rare with only a few cases described in the literature. We have encountered a mesenteric AVM in a 23-year-old girl. Considering the rarity of this entity and diagnostic dilemma, we herein describe a case of mesenteric AVM along with the review of literature. CASE PRESENTATION: A 23-year-old female presented with pain and lump in lower abdomen. During her workup to conclude a final diagnosis, Fine needle aspiration cytology (FNAC) was done. Post FNAC patient went into shock and immediately emergency laparotomy was done. The bleeding mass was resected along with involved gut and anastomosis was done. Histopathology suggested AVM. She was doing well at 2 months of follow up. CLINICAL DISCUSSION: AVM is the rare cause of ischaemic colitis. It can create a diagnostic dilemma with its unusual presentation and its rarity even for both radiologists and surgeons. Usually such malformation reported after trauma or any surgical intervention, but in our case there was no such history of trauma which makes this case more interesting. Invasive investigation is recommended in such condition but needs to be very cautious. As in this index case invasive procedure lead to severe bleeding. Although definitive treatment are embolization and surgery. CONCLUSION: Invasive procedure should be avoided in case of AVM. If angiography is not available its mandatory to keep operating room ready before any invasive procedure.